For Aliessa members, the health plan is required to pay the Medicaid default rate as now applies for such members.

For non-Aliessa members, the following guidance applies:

The Affordable Care Act (ACA) establishes minimum reimbursement amounts that health plans must pay for out-of-network emergency services. In addition, New York State Insurance and Public Health Law and regulation currently require insurers and HMOs to hold insureds harmless in the event a provider seeks payment in excess of the combined plan payment and patient in-network deductible, copayment or coinsurance for OON emergency services in a hospital.

As Essential Plan (EP) enrollees have no liability for charges in excess of any applicable in-network cost sharing, it is the expectation of the Department of Health that insurers and hospitals will make best efforts to negotiate resolution of disputes that may arise over appropriate reimbursement for out-of-network emergency services to EP enrollees without involving the enrollee, unless information is needed from the enrollee to make or support a coverage determination. Consistent with this expectation, with respect to such services, DOH discourages:

Insurers from issuing payment to patients rather than to the providers in order to avoid the necessity of providers billing patients, and;

Hospitals from balance billing patients for charges in excess of payments received from insurers.

Patterns of reimbursement or billing for emergency services received by EP enrollees that hospitals and/or insurers believe to be unreasonable should be brought to the attention of DOH.

Date of Issuance: October 14, 2015

Federal law 42 U.S.C. §1396a (bb)(5)(A) requires states to make supplemental payments to an FQHC or RHC pursuant to a contract between the FQHC and a Managed Care Organization (MCO)
and/or Independent Practice Association (IPA) for the amount, if any, that the FQHCs blended Medicaid rate exceeds the amount of payments provided under the managed care contract for
the services rendered by the FQHC. Please note that for Essential Plan Rating Groups 3 and 4 (lawfully present Aliessa immigrants 0% - 138% of FPL) the Department of Health (DOH) will
continue to issue these supplemental payments to FQHCs.

EP Guidance 1.2: Information Regarding EP Enrollment by Region

Date of Issuance: October 27, 2015

For informational purposes, the Department has developed the following charts to provide Essential Plan ´draft´ enrollment information to MCO´s and hospitals: